Discussion

Turner syndrome is a type of autosomal abnormality that affects women, with an incidence of approximately 1:2000. Its main clinical features include short stature, delayed puberty, and congenital cardiovascular malformations. ^{Reference Dobrowolski, Klisiewicz and Michalowska4,Reference Silberbach, Roos-Hesselink and Andersen5} The common cardiovascular malformations in these patients include bicuspid aortic valve malformations, aortic contractions, and aortic dissections. ^{Reference Sachdev, Matura and Sidenko1} The anomalous pulmonary venous connection accounted for only 2.9% of cardiovascular malformations in Turner syndrome. ^{Reference Mazzanti and Cacciari6} This patient had the typical manifestations of Turner syndrome such as a short stature and no menses. She had bicuspid aortic valve malformations that are common in Turner syndrome, but these were accompanied by multiple types of pulmonary vein malformations, which were rare.

Pulmonary vein abnormalities can be divided into two categories, namely, structural abnormalities with normal drainage and combined structural and drainage abnormalities. The former includes pulmonary varicose veins, but because there is no right-to-left or left-to-right shunt, these abnormalities can be asymptomatic. ^{Reference Hyun, Do and Lim3} The latter can cause cardiovascular damage due to a right-to-left shunt. This type of malformation is most commonly diagnosed by chest imaging examination. Further selective pulmonary angiography is very important when there is difficulty in distinguishing anomalous unilateral single pulmonary vein, pulmonary arteriovenous malformation, pulmonary vein atresia, and pulmonary vein stenosis. ^{Reference Engelke, Brown and Sabharwal7} In this case, echocardiography, computer tomography pulmonary angiography, cardiac catheterisation, and selective pulmonary angiography via atrial septal puncture confirmed the presence of both types of pulmonary vein abnormalities and ruled out arteriovenous malformation. The structural and morphological characteristics of the left pulmonary varicose veins of this patient fully met the conditions for the diagnosis of pulmonary varicose veins reported by Bartram. ^{Reference Batram and Strickland2}

Possible causes of pulmonary vein abnormalities may be congenital and acquired. Partial anomalous pulmonary venous connection is a congenital abnormality in most cases. In this case, the anomalous right upper pulmonary venous connection to the superior vena cava was most likely due to congenital dysplasia and may be related to Turner syndrome. Pulmonary vein stenosis can be very rarely occurs secondary to the formation of communicating branches of the pulmonary vein with pulmonary varices. ^{Reference Tajiri, Koizumi and Hara8} This patient had no history of cardiopulmonary surgery or trauma. Therefore, her malformation of upper left pulmonary vein was considered to be due to congenital abnormalities. Since a similar case has rarely been reported, ^{Reference Maillard, Cottin and Etienne-Mastroianni9,Reference Nasser, Revel and Thibault10} it is not clear whether these findings were related to Turner syndrome. And also in this patient, we innovatively performed an atrial septal puncture and performed a proposed angiogram of the malformed pulmonary veins through a catheter to further confirm the characteristics of the pulmonary venous varices, and according to the imaging characteristics of the left upper pulmonary vein in this patient, the formation of pulmonary varices was considered to be due to local obstruction of pulmonary venous return and the formation of traffic branch circulation.

The need for further invasive treatment of pulmonary venous abnormalities depends on the type of malformation and associated complications and risks. ^{Reference Hyun, Do and Lim3,Reference Tajiri, Koizumi and Hara8} Surgical correction is needed in patients with partial anomalous pulmonary venous connection if this abnormality is associated with a right-to-left shunt causing hypoxemia and related symptoms. ^{Reference Hyun, Do and Lim3} Few studies have reported that the complications of pulmonary varices include symptoms and complications. ^{Reference Perret and Fortelius11} In this case, the patient had no related symptoms. Cardiac catheterisation showed the left-to-right shunt was small. The blood flow in the varicose, twisted, haemangioma-like expanded communicating branch of the pulmonary vein was fast without signs of thrombus. The communicating branch of the upper left pulmonary vein was considered a returning path for blood flow. Therefore, no further intervention or surgery was performed. Eventually, we chose to discharge the patient from the hospital for follow-up and observation.